Healthcare Provider Details

I. General information

NPI: 1558988956
Provider Name (Legal Business Name): JENNIFER ELLEN DASHOW BS, LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNA ELLEN DASHOW BS, LADC

II. Dates (important events)

Enumeration Date: 07/01/2020
Last Update Date: 07/01/2020
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 E 78TH ST STE 100
BLOOMINGTON MN
55420-1402
US

IV. Provider business mailing address

5024 LILAC DR N
BROOKLYN CENTER MN
55429-3412
US

V. Phone/Fax

Practice location:
  • Phone: 952-234-8604
  • Fax: 952-854-5363
Mailing address:
  • Phone: 612-750-0795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number305567
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: